Page 87 - Cover Letter and Evaluation for John
P. 87
10/9/2018 Your Medicare Health Plan Details
Drug Costs During Coverage Levels
CVS Pharmacy #10434 Walgreens Mail Order Pharmacy
Walgreens - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL Refill Deductible[?] Initial Coverage Catastrophic
COST OF Frequency Coverage Gap[?] Coverage[?]
DRUG Level[?]
Carvedilol TAB 25MG Every 1
$9.06 $0.00 $0.00 $3.35 $3.40
Month
Diltiazem Hcl Sr CAP 240MG/24 Every 1
$29.84 $29.84 $29.84 $11.04 $3.40
Month
Metformin Hcl TAB 1000MG Every 1
$8.08 $0.00 $0.00 $2.99 $3.40
Month
Multaq TAB 400MG Every 1
$621.77 $621.77 $30.00 $155.44 $31.09
Month
Olmesartan
Medoxomil/Hydrochlorothiazide $31.34 Every 1 $5.00 $5.00 $11.60 $3.40
Month
TAB 40-12.5
Omega-3-Acid Ethyl Esters CAP Every 1
1GM $123.24 Month $123.24 $39.44 $45.60 $6.16
Potassium Chloride Cr
(Microencapsulated) TAB 10MEQ $26.23 Every 1 $5.00 $5.00 $9.71 $3.40
CR Month
Pravastatin Sodium TAB 10MG Every 1
$10.91 $0.00 $0.00 $4.04 $3.40
Month
MONTHLY TOTALS: $860.47 $784.85 $109.28 $243.77 $57.65
Estimated Monthly Drug Costs
CVS Pharmacy #10434 Walgreens Mail Order Pharmacy
Monthly Costs (based on January enrollment)
$483 $137 $137 $137 $258 $272 $272 $272 $272 $272 $272 $272
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Graph depicts an estimate of your monthly prescription drug costs, including any applicable premium for this plan.
Actual costs may vary.
View a more detailed explanation of these costs.
Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription drug
coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its coverage
of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic drugs as
well. The drugs eligible for the brand discount or the additional generic savings may change based on the information
we have available.
Drug Coverage Information
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S5921&plnid=413&sgmntid=0 2/4
